Getting Past the Grief over Grief

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Sidney Zisook, M.D., is director of the University of California, San Diego Residency Training Program, and a Distinguished Professor of Psychiatry at UCSD. He served as an advisor to the DSM-5’s Mood Disorder Work Group. Dr. Zisook’s research centers on mood as both a primary and secondary manifestation/disorder. Much of his research has been focused on the natural history, differentiation from depression and treatment of grief and bereavement. Currently, he is PI on a multi-site NIMH and American Foundation for Suicide Prevention research study assessing interventions to bereaved individuals with complicated grief and co-Chair of a 35-site VA Cooperative Study on Treatment Resistant Depression. He is on the Scientific Review Board of the American Foundation for Suicide Prevention (AFSP), president of the San Diego Board for the AFSP, and PI of the John A. Majda, MD Memorial Fund dedicated to facilitating research on de-stigmatizing physician depression and prevention of physician suicide. He also is co-PI of the UCSD task force on physician depression and suicide, and advisor to several trainees on studies of depression and/or suicide prevention. Dr. Zisook’s major clinical focus is treatment of adult patients with grief, mood and anxiety disorders. Using an integrated approach which combines various psychotherapeutic modalities with pharmacotherapy, Dr. Zisook provides consultation for patients with particularly chronic and refractory conditions, individuals with complicated bereavement reactions, and older persons with mood and/or anxiety disorders. Dr. Zisook received his Bachelor of Arts from the University of California at Berkeley and his medical degree from Stritch-Loyola, Chicago. He completed his residency in Psychiatry at Massachusetts General Hospital in Boston and was a clinical fellow of Harvard Medical School.

These days, I get a lot of grief about grief. I am part of the work group that changed some of the ways that grief and clinical depression are described and differentiated in the new Diagnostic and Statistical Manual of Mental Disorders, typically referred to as DSM-5. That has led to a lot of conversations with colleagues who are upset about bereavement.

The other day, a friend and fellow psychiatrist—whose son had died by suicide almost a year ago—took me aside to tell me how incensed he was about the elimination from earlier DSMs of language specifying a “bereavement exclusion.” The “exclusion” essentially detailed a two-month period of “normal grief” that people would experience after the loss of a loved one. During this period, it was all but forbidden to diagnose a patient with major depression—even if the individual had all the symptoms (which are, in important and sometimes life-threatening ways, different from grief.)

This restriction was based on the best science from the mid-1980s, the last time DSM was fully revised, but the science of bereavement and major depressive disorder has changed. Our work group found the exclusion too limiting; normal grief often lasts much longer than two months, and a small subset of patients can have major depression triggered or exacerbated by a loved one’s death, just as they can from all kinds of losses and traumas.

But critics have convinced a lot of people that our goal was to diagnose every grieving person with major depressive disorder. It especially pained me to hear my friend say, “How dare they label me with depression, as though I should have been over my grief months ago? How dare they imply I should take medications to drown my sorrow?”

He missed his son intensely long after his death, thought about him frequently, and continued to experience waves of intense anguish and yearning for his son’s return. He felt like a piece of him was missing and that it would never be found. He had occasional problems sleeping through the night, difficulty watching some of the TV shows he and his son had enjoyed so much together. And he had yet to return to playing golf, which the two of them had also shared. He was fully back to work and seeing patients, but he couldn’t help worrying more than in the past when caring for potentially suicidal young people.

Despite his anger, he readily accepted my hug, my offer to take him to lunch and my eagerness to listen. I told him how sorry I was for his loss, that it was impossible for me to imagine how difficult it had been for him and his wife, and that I thought his continued grief was perfectly understandable—and in no way indicative of major depression. Like most people after a loss, he needed comfort, not treatment. We agreed to meet at a later time to talk about the bereavement exclusion. It was a fascinating discussion.

I made it clear to him that the elimination of the bereavement exclusion in no way, shape or form dictates how intense his grief should be or how long it should last. His feelings were absolutely normal. I also stressed how dropping the exclusion does not re-label grief as major depression, nor does it medicalize grief. That is not to suggest that grief is not “depressing.” For many people, grief is very depressing, if by that you mean feeling sad, blue and down in the dumps. But those emotions are not the same as having a major depressive disorder, a serious clinical condition that certainly is not part of normal grief.

Our work group changed the grief language in DSM-5 to make sure clinicians and patients understand that major depression can occur in someone who is bereaved, just as it can occur in someone who is going through a divorce, facing a sudden disability or terminal illness, or struggling with serious financial troubles. There are no known clinically meaningful differences in the severity, course or treatment response of major depressive episodes that occur after the death of a loved one compared to those occurring in any other context. According to the best research available, any very stressful life event can trigger a major depressive episode in a vulnerable person; regardless of the context in which it occurs, prompt recognition and appropriate treatment can be life-promoting and even life-saving.

In addition, eliminating the bereavement exclusion in no way suggests that intense grief should be treated. Just the opposite. It makes clear, for the first time, how to spot and properly diagnose those individuals in whom major depression is triggered by the death of a relative or close friend —which is the same way we diagnose everyone else. And treatment with medications is by no means automatic or the only option. In some cases, education and support during a period of “watchful waiting” may be the most appropriate intervention; in other cases—for example, when the person has had previous bouts of serious depression, or when the major depressive episode is particularly severe and persistent—more formal treatments with evidence-based psychotherapies and/or medications might be the best option.

My friend and I discussed how these changes might affect primary care physicians, who write most of the prescriptions for antidepressants and so, technically, diagnose most depressions. One of the main concerns voiced was that the bereavement exclusion, however clumsy and unscientific, was the only thing keeping some family physicians from “giving every grieving patient an antidepressant after a 10-minute evaluation!” But we both agreed that the criteria for major depression should not be jiggered so as to anticipate poor practice by other clinicians. Instead, psychiatrists must provide more training and consultation to the other treatment professionals who might see grieving patients.

By the time our lunch ended, my friend’s view had softened. As we talked about the difference between his extended grief and a major depressive disorder, he said that it maybe was time for him to look into a suicide survivors support group. He even allowed that, given his knowledge of the potential consequences of untreated major depression, he would assess a bereaved individual who met the diagnostic criteria in the same careful way he would any other patient.

We again hugged, and then we both headed back to work. In the end, we agreed: It is time to stop grieving the loss of the bereavement exclusion.

Click here to see a video of DSM-5’s Task Force Chair Dr. David Kupfer discussing the bereavement exclusion.

About the Author: Sidney Zisook, M.D., is director of the University of California, San Diego Residency Training Program, and a Distinguished Professor of Psychiatry at UCSD. He served as an advisor to the DSM-5’s Mood Disorder Work Group. Dr. Zisook’s research centers on mood as both a primary and secondary manifestation/disorder. Much of his research has been focused on the natural history, differentiation from depression and treatment of grief and bereavement. Currently, he is PI on a multi-site NIMH and American Foundation for Suicide Prevention research study assessing interventions to bereaved individuals with complicated grief and co-Chair of a 35-site VA Cooperative Study on Treatment Resistant Depression. He is on the Scientific Review Board of the American Foundation for Suicide Prevention (AFSP), president of the San Diego Board for the AFSP, and PI of the John A. Majda, MD Memorial Fund dedicated to facilitating research on de-stigmatizing physician depression and prevention of physician suicide. He also is co-PI of the UCSD task force on physician depression and suicide, and advisor to several trainees on studies of depression and/or suicide prevention. Dr. Zisook’s major clinical focus is treatment of adult patients with grief, mood and anxiety disorders. Using an integrated approach which combines various psychotherapeutic modalities with pharmacotherapy, Dr. Zisook provides consultation for patients with particularly chronic and refractory conditions, individuals with complicated bereavement reactions, and older persons with mood and/or anxiety disorders. Dr. Zisook received his Bachelor of Arts from the University of California at Berkeley and his medical degree from Stritch-Loyola, Chicago. He completed his residency in Psychiatry at Massachusetts General Hospital in Boston and was a clinical fellow of Harvard Medical School.

6 Comments

Regardless of what your group’s intent or goal was, the proof will be in the pudding: whether those suffering from grief are inappropriately diagnosed as suffering from long term, major depression – and suffering negative consequences as a result of that treatment. Having been near someone treated for major depression (or, varyingly, psychosis) I suspect that otherwise healthy individuals subjected to such treatments might not fully recover…

Perhaps you can enlighten us as to the ways in which depression and grief are different as you say. The literature actually suggests otherwise. Thoughts of self-harm, damage to self-esteem and feelings of hopelessness are common amongst many non-depressed who are bereaved, depending on circumstances of the loss, nature of the relationship, and social responses. Mental/medical health professionals have little or no training or experience in grief. I’d refer you and readers to the brilliant work of Jerome Wakefield, PhD (NYU), David Healy, MD, Ben Goldacre, MD amongst others who may have a different perspective on this issue. http://www.nyu.edu/socialwork/pdf/wakefield.depression.threshold.pdf

I commend my colleague, Dr. Zisook, for his humane and illuminating article (Disclosure: I have co-authored several articles with Dr. Zisook and also commented on early drafts of the present article).

The fear that the entirely understandable grief of bereavement will be “inappropriately diagnosed” as major depressive disorder(MDD)has never been borne out, to my knowledge, in any published research studies of actual patients. In contrast, there are dozens of studies showing that MDD is often entirely missed, or inadequately treated, in various clinical settings (e.g., primary care offices). See, e.g., González et al, Depression care in the United States: too little for too few. Arch Gen Psychiatry. 2010 Jan;67(1):37-46). Furthermore, the risk of completed suicide in MDD (approximately 4 in 100) far outweighs the risk of “over-diagnosing” normal grief as major depression–a situation that can readily be reversed if the patient’s clinical picture improves or stabilizes shortly after diagnosis.

Contrary to a popular misconception, there are indeed substantial differences between “ordinary” or “normal” grief associated with loss, and MDD. For example, bereaved persons with normal grief often experience a mixture of sadness and more pleasant emotions, as they recall memories of the deceased. Anguish and pain are usually experienced in “waves” or “pangs,” rather than continuously, as is usually true in major depression. The normally grieving individual typically maintains the hope that things will get better. In contrast, the clinically depressed patient’s mood is almost uniformly one of gloom, despair, and hopelessness–nearly all day, nearly every day. The bereaved individual usually maintains a strong emotional connection with friends and family, and often can be consoled by them. The person suffering a severe major depressive disorder is usually too self-focused and emotionally “cut off” to enjoy the company of others. Indeed, Dr. Kay R. Jamison has pointed out that “The capacity to be consoled is a consequential distinction between grief and depression.”

For more on differences between grief and major depression, please see:

Pies R: How the Public is Being Misinformed about Grief. Psychcentral.

Disclosure: Dr. Pies, who recently retired from clinical practice after nearly 30 years as a specialist in mood disorders, reports no financial or other conflicts of interest with respect to this letter.

The risk of suicide in animal and human models is also exacerbated by impulsivity, aggression, irritability, and learned helplessness (see Malkesman et al 2009). Perhaps, we should also screen for these? I disagree with the rhetoric that MDD is not being diagnosed. In fact, it’s more likely, at least in my region of the U.S. (Midwest) that grief is being misdiagnosed much more frequently as other psychopathologies from anxiety (NOS) to MDD to various other diseases. Thus far I have not yet read an intelligent response to the critique of poor reliability tests for MDD. If we can’t get that right, we should start over. Again, Wakefield’s work illuminates: http://www.nyu.edu/socialwork/pdf/wakefield.depression.threshold.pdf

As far as I know, the study of bupropion (Wellbutrin) in major depression post bereavement is the only evidence Dr. Zisook brings forward for his claim of successfully treating such patients. This uncontrolled study is laughable. It was sponsored by the drug’s manufacturer, for whom Dr. Zisook also gave paid speeches. It was uncontrolled, so much of the reported improvement would be expected had there been a placebo treated comparison group. There were no self report depression measures, so we don’t know whether the patients also thought they had improved in terms of major depression. Their self reported grief scores improved, but once again we have no comparison group, and the natural course is for improvement.

But most of all, it was a tiny study in a skewed population – they enrolled fewer than 1% of the subjects they invited to participate (22 out of 3998, to be exact, or 0.55%). It is impermissible to generalize from this minuscule sample in order to make broad policy for DSM-5.

Dr. Zisook glossed over the fact that many people he would give a hug to, like his friend, do indeed meet the nominal criteria for major depression, as Paula Clayton taught us decades ago, even while we acknowledge that their grieving is a normal process. In other words, there are many false positive diagnoses of major depression among the bereaved. Dr. Zisook doesn’t explain how he identifies the ones who need more than a hug.

As a neuropsychologist and colleague at UCSD, I believe Dr. Zisook’s work in helping remove the bereavement exclusion promotes an understanding of each individual’s unique response to painful loss. While we share humanity, we are highly individual in our temperaments, life experiences, genetics, and trans-generational legacies; some of the forces that shape response to loss.

When I lost my father from an abrupt cardiac arrest, shortly before 9/11, I plunged into profound grief. This grief occasionally was tempered by brief moments of relief, as my father had been slowly disappearing with dementia before my eyes. As Dr. Zisook would have appreciated even then, I was in a profound depression given the severity of my neurovegetative responses (i.e. no appetite, sleep, interest, energy, or concentration). Time suspended until 9/11, when my grief vaulted past my father’s loss into a paralyzing shock before turning towards a curious sense of aliveness, born out of empathic resonance to both the horrific loss and heroic life in NYC. The polarity of my experience reflects the amazing flexibility in our nervous systems to die in mirrored resonance with those we love and to live in recognition of the truth of our being.

For those individuals who are captured in a persistent, symptomatic response of depression, early in the stages of grief; I find it only helpful that we can consider whether clinical depression is present. I applaud Dr. Zisook’s work in helping all of us understand that there is nothing uncomplicated about bereavement and depression.

We are beings of extraordinary complexity with vast differences in our responses. We also share predictable responses that warrant effective treatments. Diagnosis is both an art form and a science. Removing the exclusion allows us all to practice our scientific art from a person-centered perspective; acknowledging the uniqueness of our grieving.